Surgery for stomach cancer

Surgery is often used to treat stomach cancer. The type of surgery you have depends mainly on the size and location of the tumour. When planning surgery, your healthcare team will also consider other factors, such as:

the type of stomach cancer

your age

how well your organs are working

your nutritional status (a measure of how well your body’s nutritional needs are being met)

Surgery may be done for different reasons. You may have surgery to:

try to cure the cancer by completely removing all of the tumour and surrounding lymph nodes

reconstruct the gastrointestinal (GI) tract after the stomach has been removed (this is done at the time of the original surgery)

ease symptoms of advanced stomach cancer (palliative treatment)

Evaluation before surgery

People need to be as healthy as possible before they have surgery for stomach cancer because it can be a difficult operation that may be hard to recover from. A person with stomach cancer is thoroughly evaluated before surgery. The following may be included to make an evaluation:

A complete medical history and physical exam may be done. Tell the surgeon if you’ve had previous surgeries in the abdomen. This may affect the ability to safely remove the stomach and reconstruct the gastrointestinal tract.

Blood tests, such as a complete blood count, blood chemistry, coagulation (blood clotting) profile, and liver and kidney function tests may be done.

Heart and lung function tests are done to make sure you are healthy enough to have surgery. You may learn special coughing and breathing exercises to help keep your lungs clear. It is very important to quit smoking at least one month before surgery. Smoking can increase your risk of lung infection (pneumonia), poor wound healing, stroke and blood clots.

A nutritional assessment is done to find out your weight and how much food you’ve been eating. People with stomach cancer may be malnourished and underweight if they were unable to eat before being diagnosed. You may need nutritional supplements, a feeding tube or intravenous (IV) feeding before and after surgery to gain weight and improve your nutrition and health.

The following types of surgery are used to treat stomach cancer. You may also have other treatments before or after surgery.

Endoscopic mucosal resection

Endoscopic mucosal resection (EMR) is a very specialized surgery used to treat small (less than 2 cm) early stage stomach cancer that has not spread beyond the inner lining of the stomach (called the mucosa). EMR is done using an endoscopeendoscopeA thin, tube-like instrument with a light and lens used to examine or treat organs or structures in the body. placed through the mouth, down the throat and into the stomach. Salt water is injected under the tumour to lift it away from the stomach wall so it can be removed more easily.

If cancer cells are on or near the cut surface of the tissue removed by surgery (called positive surgical margins), you will have more surgery to remove the stomach. If no cancer is found on or close to the margin, you will have an endoscopy every year to check the lining of the stomach for recurrence (to see if cancer has come back).

In Canada, very few stomach cancers are treated this way because stomach cancer is rarely found at such an early stage.

Laparoscopic staging and exam

Laparoscopic staging and exam is done using a laparoscopelaparoscopeA procedure that uses an endoscope (a thin, tube-like instrument with a light and lens) to examine or treat organs inside the abdomen and pelvis. that is put into the abdomen through small incisions (surgical cuts) in the abdomen. This may be done to see if the cancer has spread from the stomach to other parts of the abdomen (for example, to the liver or pancreas). Doctors may find smaller tumours that didn’t show up on imaging tests. The results of the laparoscopy help the doctor to decide which other type of surgery is needed.

Limited surgical resection

A limited surgical resection (also called a wedge resection) removes a section of the stomach wall that contains the tumour along with a healthy margin around the tumour. A limited surgical resection is sometimes used to treat small (less than 3 cm) early stage stomach cancer.

Often an endoscopy is used with a limited surgical resection to locate the exact position of the tumour. A limited surgical resection may be done by open surgery to the abdomen (called a laparotomy) or by laparoscopy.

Gastrectomy

A gastrectomy is the most common surgery to treat stomach cancer. A gastrectomy is the removal of all or part of the stomach through an incision in the abdomen. Sometimes other organs or structures like the spleen or omentumomentumA fold in the peritoneum (the membrane that lines the walls of the abdomen and pelvis) that covers and supports organs and blood vessels in the abdomen. are also removed during a gastrectomy.

There are different types of gastrectomy. A total gastrectomy removes all of the stomach. A partial gastrectomy removes part of the stomach, usually the upper (proximal) or lower (distal) half. The type of gastrectomy will depend on the location of the tumour in the stomach and the stage of the cancer.

Most people will have a gastrectomy done through a large incision in the abdomen (laparotomy). In recent years, some surgeons are removing the stomach by laparoscopiclaparoscopicA procedure that uses an endoscope (a thin, tube-like instrument with a light and lens) to examine or treat organs inside the abdomen and pelvis. surgery.

Distal subtotal gastrectomy

A distal subtotal gastrectomy is used for tumours that are found in the lower (distal) part of the stomach. This surgery removes:

the lower part of the stomach (the tumour along with a margin of healthy tissue around it)

part of the duodenumduodenumThe first part of the small intestine that receives partially digested food from the stomach, absorbs nutrients and passes digested food to the jejunum. The duodenum also receives digestive juices from the pancreas and bile (a yellow-green fluid that helps digest fat) from the liver and gallbladder.

the lymph nodes in the area around the stomach

The gastrointestinal tract is usually reconstructed by connecting a part of the small intestine (called the jejunumjejunumThe middle part of the small intestine that receives partially digested food from the duodenum, absorbs most nutrients and fat and passes the remaining food matter to the ileum.) to the remaining upper part of the stomach. The bile duct is moved to enter the remaining part of the duodenum, farther down from where the stomach and jejunum are attached (Roux-en-Y procedure).

Proximal gastrectomy

A proximal gastrectomy is used for tumours in the upper (proximal) part of the stomach and in the area where the stomach joins the esophagus (gastroesophageal junction). This surgery removes:

the upper part of the stomach (the tumour along with a margin of healthy tissue around it)

some or all of the lower part of the esophagus

the lymph nodes in the area around the stomach

The gastrointestinal tract is then reconstructed by pulling the remaining part of the stomach up to the remaining upper part of the esophagus (gastric pull-up).

Total gastrectomy

A total gastrectomy is used for stomach cancer that has spread throughout the stomach or for a stomach tumour in the middle or upper part of the stomach. This surgery removes:

the whole stomach

the lower part of the esophagusesophagusThe muscular tube in the neck and chest through which food passes from the pharynx (throat) to the stomach.

the first part of the duodenum

part or all of any nearby organs, such as the pancreas, spleen or liver, where the stomach tumour has spread

the lymph nodes in the area around the stomach, near the area of the tumour

The gastrointestinal tract is then rebuilt (reconstructed):

The remaining part of the duodenum is separated from the jejunum while still attached to the bile duct from the liver and the pancreatic duct from the pancreas.

The jejunum is connected to the remaining end of the esophagus.

The remaining duodenum is connected farther down the jejunum from where the esophagus and jejunum are attached (Roux-en-Y procedure).

This reconstruction allows the bile and pancreatic juices to enter the digestive system without harming the remaining esophagus.

Lymph node dissection (removal) is classified by the location of the lymph nodes that are removed. A D1 lymph node dissection removes the lymph nodes attached to the outer wall of the area of the stomach that contains the tumour. A D2 lymph node dissection removes D1 lymph nodes plus the lymph nodes around several large blood vessels near the stomach. A D2 lymph node dissection is a longer and more complicated operation.

Palliative surgery

Surgery may be used to relieve the symptoms of advanced stomach cancer, including:

bleeding

pain

the inability to eat

obstruction, or blockage (tumour may block the passage of food into or through the stomach)

perforation (tumour may grow through the wall of the stomach, creating a hole into the abdomen)

The type of palliative surgery will depend on your symptoms, the location of the stomach tumour and your overall health, nutrition and performance statusperformance statusThe measure of how well a person is able to perform ordinary tasks and carry out daily activities..

Stomach bypass surgery

Surgery may be done to change the flow of food or fluids around a stomach tumour that is blocking the stomach or esophagus. The part of the stomach that is above the blockage is cut and then reattached to the small intestine. This allows the food to move through the stomach and into the small intestine. Stomach bypass surgery is also called a gastrojejunostomy.

Stomach bypass surgery may be done if you cannot have a gastrectomy because of health problems or if removing the tumour would not improve your quality of life.

Limited surgical resection

A limited surgical resection (described above) may also be used for people with advanced stomach cancer. The goal in this case is to remove as much of the tumour as possible to try to relieve a blockage or bleeding that is hard to stop.

Placement of a stent

A stent is a hollow metal or plastic tube. Stents may be used if a tumour is blocking the opening of the stomach near the esophagus. It will allow a person with advanced stomach cancer to swallow more easily. A stent may also be placed at the opening to the duodenum, to allow the food to pass from the stomach into the small intestine.

The doctor places the stent using an endoscopeendoscopeA thin, tube-like instrument with a light and lens used to examine or treat organs or structures in the body.. The endoscope is passed through the mouth, down the esophagus and into the stomach.

Endoscopic tumour ablation

Endoscopic tumour ablation uses laser surgery to destroy some of the stomach tumour. This technique may be used in people who can’t have surgery. This may be done to stop bleeding or to relieve a tumour blockage in people with advanced stomach cancer. This procedure may also help a person to eat more easily.

Feeding tube placement

If other surgery or other methods cannot relieve a blockage caused by a stomach tumour, a person with advanced stomach cancer may have a feeding tube placed through a surgical opening in the abdomen. A feeding tube may also be used for a short time after surgery for stomach cancer.

A feeding tube is used to give liquid nutrition to help maintain a healthy weight. The tube may also be used to give medicines. A feeding tube may be placed into the:

stomach (called a gastrostomy tube, or G-tube)

small intestine (called a jejunostomy tube, or J-tube)

Surgery for a bowel obstruction

A bowel obstruction is when the small intestine or colon is partly or completely blocked. The blockage prevents food, fluids and gas from passing through the intestines normally. If you have a bowel obstruction, you may need surgery to remove or bypass the part of the intestine that is blocked.